Imported leishmaniasis in Sweden 1993-2016.

In Sweden, leishmaniasis is an imported disease and its epidemiology and incidence were not known until now. We conducted a retrospective, nationwide, epidemiological study from 1993 to 2016. Probable cases were patients with leishmaniasis diagnoses reported to the Swedish Patient registry, collecting data on admitted patients in Swedish healthcare since 1993 and out-patient visits since 2001. Confirmed cases were those with a laboratory test positive for leishmaniasis during 1993-2016. 299 probable cases and 182 confirmed cases were identified. Annual incidence ranged from 0.023 to 0.35 per 100 000 with a rapid increase in the last 4 years. Of 182 laboratory-verified cases, 96 were diagnosed from 2013 to 2016, and in this group, almost half of the patients were children under 18 years. Patients presented in different healthcare settings in all regions of Sweden. Cutaneous leishmaniasis was the most common clinical manifestation and the majority of infections were acquired in Asia including the Middle East, specifically Syria and Afghanistan. Leishmania tropica was responsible for the majority of cases (42%). A combination of laboratory methods increased the sensitivity of diagnosis among confirmed cases. In 2016, one-tenth of the Swedish population were born in Leishmania-endemic countries and many Swedes travel to these countries for work or vacation. Swedish residents who have spent time in Leishmania-endemic areas, could be at risk of developing disease some time during their lives. Increased awareness and knowledge are needed for correct diagnosis and management of leishmaniasis in Sweden.

Ultrasound-assessed plaque occurrence in the carotid and femoral arteries are independent predictors of cardiovascular events in middle-aged men during 10 years of follow-up.

OBJECTIVES: To examine if plaques in the carotid and femoral arteries were associated with cardiovascular events during a 10-year follow-up independently of usual risk factors for such diseases. METHODS: Plaque occurrence in both carotid arteries, and in the right femoral artery were assessed at baseline by B-mode ultrasound in a population-based sample of 58-year-old men (n=391) with no cardiovascular disease, and varying degrees of obesity and insulin sensitivity at entry. Anthropometry and blood pressure were recorded. Fasting venous blood samples were used for measurement of cardiovascular risk factors. Cardiovascular events occurring during follow-up were obtained by access to register data. RESULTS: Systolic blood pressure, serum triglycerides and waist-hip ratio as well as baseline occurrence of carotid and femoral plaques were associated with events. Logistic multi-variate analyses showed that carotid plaques (OR 2.09, 95% CI 1.05-4.16, p=0.037), femoral plaques (OR 1.99, 95% CI 1.01-3.91, p=0.047) and concomitant presence of carotid, and femoral plaques (OR 2.53, 95% CI 1.23-5.21, p=0.011) were associated with cardiovascular events independently of other risk factors. Plaques occurred in 0-3 arteries and there was a parallel increase in cardiovascular risk (p=0.004). CONCLUSION: Occurrence of carotid or femoral plaques at baseline had similar predictive value for cardiovascular events. Increased plaque burden, with plaques in both carotid and femoral arteries increased the cardiovascular risk further. Hence, the results from this study indicate that ultrasound examination of both the carotid and femoral arteries was the preferred method to predict cardiovascular risk.

Brain magnetic resonance imaging does not contribute to the diagnosis of chronic neuroborreliosis.

BACKGROUND: Borrelia infections, especially chronic neuroborreliosis (NB), may cause considerable diagnostic problems. This diagnosis is based on symptoms and findings in the cerebrospinal fluid but is not always conclusive. PURPOSE: To evaluate brain magnetic resonance imaging (MRI) in chronic NB, to compare the findings with healthy controls, and to correlate MRI findings with disease duration. MATERIAL AND METHODS: Sixteen well-characterized patients with chronic NB and 16 matched controls were examined in a 1.5T scanner with a standard head coil. T1- (with and without gadolinium), T2-, and diffusion-weighted imaging plus fluid-attenuated inversion recovery (FLAIR) imaging were used. RESULTS: White matter lesions and lesions in the basal ganglia were seen in 12 patients and 10 controls (no significant difference). Subependymal lesions were detected in patients down to the age of 25 and in the controls down to the age of 43. The number of lesions was correlated to age both in patients (rho = 0.83, P<0.01) and in controls (rho = 0.61, P<0.05), but not to the duration of disease. Most lesions were detected with FLAIR, but many also with T2-weighted imaging. CONCLUSION: A number of MRI findings were detected in patients with chronic NB, although the findings were unspecific when compared with matched controls and did not correlate with disease duration. However, subependymal lesions may constitute a potential finding in chronic NB.

Prevalence of iron deficiency with and without concurrent anemia in population groups with high prevalences of malaria and other infections: a study in Côte d'Ivoire.

BACKGROUND: Iron deficiency is highly prevalent in most developing countries. However, its detection is often obscured by infections and inflammatory disorders that are common in the same populations. OBJECTIVE: The aim of this study was to estimate the prevalence of iron deficiency with or without concurrent anemia in different population groups from Côte d'Ivoire and to evaluate the influence of infectious and inflammatory disorders on iron-status indexes. DESIGN: Blood samples from 1573 children, women, and men were analyzed for hemoglobin, serum ferritin, zinc protoporphyrin, and serum transferrin receptor. C-reactive protein was used as the indicator of inflammation or infection, and samples were screened for malarial parasites and hemoglobinopathies. Iron deficiency was defined as 2 of 3 iron-status indexes outside the cutoff values, and iron deficiency anemia (IDA) was defined as iron deficiency with concurrent anemia. Pearson's correlation coefficients were used to evaluate the influence of malaria and inflammation on iron-status indexes. RESULTS: The prevalence of iron deficiency was 41-63% in the women and children and 13% in the men, whereas the prevalence of IDA was 20-39% in the women and children and 4% in the men. The detection of iron deficiency and IDA was obscured by the high prevalence of inflammatory disorders. CONCLUSIONS: Iron deficiency and IDA are highly prevalent in the women and children in Côte d'Ivoire. Iron deficiency was detected in approximately 50% of anemic women and children, which indicates that hemoglobin alone is not a good indicator of iron status when inflammatory disorders are highly prevalent. The serum transferrin receptor is the most useful single indicator of iron deficiency because it was the only iron-status index unaffected by malaria or inflammation.

Selenium absorption and retention from a selenite- or selenate-fortified milk-based formula in men measured by a stable-isotope technique.

The present study was designed to determine the apparent absorption and retention of the inorganic Se compounds SeO3(2-) and SeO4(2-), which are commonly used for Se fortification of clinical nutrition products and infant formulas. Ten healthy men were fed a milk-based formula labelled with 40 microg Se as 74SeO3(2-) or 76SeO4(2-) on two consecutive days using a randomised crossover design. Se stable-isotope analysis of 9 d complete collections of urine and faeces was used to calculate apparent Se absorption and retention. Se retention from 74SeO3(2-) (41.0 (SD 8.4) %) and from 76SeO4(2-) (46.0 (SD 7.9) %) was not significantly different (P > 0.05). However, Se absorption was significantly higher from SeO4(2-) than from SeO3(2-) (91.3 (SD 1.4) % v. 50.2 (SD 7.8) %, P < 0.05). Urinary excretion of the administered dose was 9.2 (SD 1.8) % for 74SeO3(2-) and 45.3 (SD 8.2) % for 76SeO4(2-) (P < 0.05). Urinary Se excretion kinetics differed significantly for the two Se compounds; 90 % of the total urinary Se was excreted after 121 h for 74SeO32- and after 40 h for 76SeO42- These results suggest that although Se absorption and urinary excretion differ for SeO3(2-) and SeO4(2-), both Se compounds are equally well retained when administered at a relatively low dose (40 microg Se). The nutritional impact of Se fortification of foods would thus be expected to be similar when SeO4(2-) or SeO3(2-) are used.

Improving iron absorption from a Peruvian school breakfast meal by adding ascorbic acid or Na2EDTA.

BACKGROUND: Iron-fortified school breakfasts have been introduced in Peru to combat childhood iron deficiency. OBJECTIVE: We evaluated whether iron absorption from a school breakfast meal was improved by increasing the ascorbic acid content or by adding an alternative enhancer of iron absorption, Na2EDTA. DESIGN: In a crossover design, iron absorption from test meals was evaluated by erythrocyte incorporation of 58Fe and 57Fe. The test meals (wheat bread and a drink containing cereal, milk, and soy) contained 14 mg added Fe (as ferrous sulfate) including 2.0-2.6 mg 58Fe or 4.0-7.0 mg 57Fe. RESULTS: Geometric mean iron absorption increased significantly from 5.1% to 8.2% after the molar ratio of ascorbic acid to fortification iron was increased from 0.6:1 to 1.6:1 (P < 0.01; n = 9). Geometric mean iron absorption increased significantly from 2.9% to 3.8%, from 2.2% to 3.5%, and from 2.4% to 3.7% after addition of Na2EDTA at molar ratios relative to fortification iron of 0.3:1, 0.7:1, and 1:1, respectively, compared with test meals containing no added enhancers (P < 0.01; n = 10 for all). Iron absorption after addition of ascorbic acid (molar ratio 0.6:1) was not significantly different from that after addition of Na2EDTA (molar ratio 0.7:1). CONCLUSIONS: Ascorbic acid and Na2EDTA did not differ significantly in their enhancing effects on iron absorption at molar ratios of 0.6:1 to 0.7:1 relative to fortification iron. Additional ascorbic acid (molar ratio 1.6:1) increased iron absorption significantly. Increasing the molar ratio of Na2EDTA to fortification iron from 0.3:1 to 1:1 had no effect on iron absorption.

Iron absorption from experimental infant formulas based on pea (Pisum sativum)-protein isolate: the effect of phytic acid and ascorbic acid.

Infant formula based on pea (Pisum sativum)-protein isolate has been suggested as an alternative to soybean formula in countries where soybean is not a native crop, or when soybean protein cannot be used due to allergic reactions or intolerances. In the present study, Fe absorption from experimental infant formulas based on pea-protein isolate was measured in healthy non-anaemic young women. The influence of phytic acid and ascorbic acid on Fe absorption was evaluated, using a stable-isotope technique based on incorporation of Fe stable-isotope labels into erythrocytes 14 d after administration. Geometric mean Fe absorption increased from 20.7 (+1 SD 41.6, -1 SD 10.3) % to 33.1 (+1 SD 58.6, -1 SD 18.7) %; (P < 0.0001; n 10) after enzymic degradation of virtually all phytic acid. Doubling the molar ratio Fe:ascorbic acid from 1:2.1 to 1:4.2 in the infant formula with native phytic acid content also increased Fe absorption significantly (P < 0.0001; n 10); geometric mean Fe absorption increased from 14.8 (+1 SD 32.1, -1 SD 6.8) % to 22.1 (+1 SD 47.2, -1 SD 10.4) %. These results confirm the inhibitory and enhancing effects of phytic acid and ascorbic acid respectively on Fe absorption, but also indicate relatively high fractional Fe absorption from the pea-protein-based formulas. After adjusting for differences in Fe status, our data indicate that Fe absorption from dephytinised pea protein might be less inhibitory than dephytinised soybean protein as measured in a previous study (Hurrell et al. 1998).

Iron bioavailability in infants from an infant cereal fortified with ferric pyrophosphate or ferrous fumarate.

BACKGROUND: Infant cereals are commonly fortified with insoluble iron compounds with low relative bioavailability, such as ferric pyrophosphate, because of organoleptic changes that occur after addition of water-soluble iron sources. OBJECTIVE: Our objective was to compare iron bioavailability from ferric pyrophosphate with an alternative iron source that is soluble in dilute acid, ferrous fumarate, and to evaluate the influence of ascorbic acid on iron bioavailability from ferrous fumarate in infants. DESIGN: Iron bioavailability was measured as the incorporation of stable iron isotopes into erythrocytes 14 d after administration of labeled test meals (25 g dry wheat and soy infant cereal, 100 g water, and 2.5 mg Fe as [57Fe]ferric pyrophosphate or [57Fe]ferrous fumarate). Ascorbic acid was added to all test meals (25 mg in study 1 or 25 or 50 mg in study 2). Infants were fed each test meal on 4 consecutive days under standardized conditions. The 2 different test meals within each study were administered 2 wk apart in a crossover design. RESULTS: Geometric mean iron bioavailability was significantly higher from [57Fe]ferrous fumarate than from [57Fe]ferric pyrophosphate [4.1% (range: 1.7-14.7%) compared with 1.3% (range: 0. 7-2.7%); n = 8, P = 0.008]. In this study, doubling the ascorbic acid content did not further enhance iron bioavailability; the geometric means (range) were 3.4% (1.9-6.6%) and 4.2% (1.2-18.7%) for the test meals with 25 and 50 mg ascorbic acid added, respectively (n = 9). CONCLUSION: Iron bioavailability from iron-fortified infant cereals can be improved by using an iron compound with high relative bioavailability and by ensuring adequate ascorbic acid content of the product.

Erythrocyte incorporation of iron by infants: iron bioavailability from a low-iron infant formula and an evaluation of the usefulness of correcting erythrocyte incorporation values, using a reference dose or plasma ferritin concentrations.

Bioavailability of iron (Fe) from a low-Fe infant formula was determined by erythrocyte incorporation of 58Fe 14 d after administration in ten healthy, non-Fe-deficient infants. Two feeding protocols were compared, with each infant acting as his/her own control. At 140 and 154 d of age, infants were fed 1000 g of 58Fe-labelled formula (1.44 mg total Fe/1000 g) as six feeds over 24 h (Protocol A) or as two feeds/day on three consecutive days (Protocol B). A water solution with 57Fe and ascorbic acid was given separately as a reference dose in both study protocols. Erythrocyte incorporation of 58Fe and 57Fe was determined by thermal ionisation mass spectrometry. Geometric mean 58Fe incorporation was 7.6% (range 3.3-13.5%) with Protocol A as compared to 10.6% (range 6.7-18.6%) with Protocol B (P = 0.05); paired t test. Inter-individual variability of 58Fe was not reduced by correcting for the incorporation of 57Fe from the reference dose, or by correcting for plasma ferritin concentration. Fractional erythrocyte incorporation of Fe from low-Fe infant formula was in the same range as our earlier published data on erythrocyte incorporation of Fe from human milk extrinsically labelled with 58Fe (Davidsson et al. 1994a). The methodological evaluations included in this study clearly indicate the importance of using standardised study protocols when evaluating Fe bioavailability in infants. Corrections of erythrocyte incorporation data based on plasma ferritin or erythrocyte incorporation of Fe from a reference dose were not found to be useful.

MRI screening of the cerebellopontine angle and inner ear with fast spin-echo T2 technique.

In patients with unilateral hearing loss and dizziness it is important to rule out a cerebellopontine angle process. This is often done by audiological and otoneurological investigations. However, in many cases we must rely on the imaging of the temporal bone and the cerebello-brainstem area. The paper has presented the three dimensional (3D) Fast Spin-Echo (FSE) T2 weighted, 0.7 mm thick MR images, which in addition to being quick, does not require the use of expensive contrast material. Between September 1996 and November 1997, 152 patients with unilateral hearing loss and/or balance disorders were investigated. In normal cases the 7th and 8th nerves could be followed accurately from the brainstem to the internal auditory meatus. The found tumors were hypointense compared to the cerebrospinal fluid and could be outlined with reasonable accuracy even without gadolinium contrast. The inner ear had high signal, like cerebrospinal fluid. The patency of the cochlea could be estimated accurately. Thus, 3D FSE T2 weighted images can reliably differentiate between patients with and without pathologies of the cerebellopontine angle. The use of gadolinium contrast could be avoided in most of the cases, but contrast is necessary for differential diagnostic purposes in patients with alterations in the cerebellopontine angle or in doubtful cases.

Deinstitutionalization and community based psychiatry--some aspects from literature.

The dramatic changes in the transformation of psychiatry can be summarized in a few words; deinstitutionalization, community psychiatry, team-work, sectorization, continuity of care and comprehensiveness. A model for planning, implementation and evaluation of community health facilities is presented. Risks and benefits with the community approach is discussed as well as the economy. Saving from the closing down of the mental hospital should be adequate to fund community services for the long stay population. But other wise community mental health oriented services should not be considered a way of saving money.

Respiratory monitoring during MR imaging. The clinical value of a new fibre-optical monitor.

PURPOSE: To assess the clinical utility of a fibre-optical monitor for respiratory monitoring in patients undergoing MR imaging without general anaesthesia. MATERIAL AND METHODS: One hundred consecutive patients were included at each of 3 MR units (300 patients in total). The technicians estimated the value of monitoring the respiratory rate on a 5-graded scale. Conditions that might complicate the MR examination were noted. RESULTS: The respiratory monitor was well tolerated by 99% of the patients. It was rated as valuable or very valuable in one-third of the total group, but in slightly more than two-thirds of the group of patients with some condition that might have complicated the MR examination. The estimated value of respiratory rate monitoring did not correlate to the age or sex of the patients, the type of examination, or to whether contrast medium was used or not, but it was significantly more often considered valuable in patients placed in the head-first position than in those placed in feet-first. CONCLUSION: Respiratory rate monitoring during MR imaging seems to be valuable in many patients, particularly if some condition that might complicate the MR examination is present.

Sodium iron EDTA [NaFe(III)EDTA] as a food fortificant does not influence absorption and urinary excretion of manganese in healthy adults.

NaFe(III)EDTA is a promising iron (Fe) compound for food fortification programs because of its high Fe bioavailability from meals containing dietary inhibitors of Fe absorption such as phytic acid. However, this Fe compound is not currently used in any large-scale fortification program because of concern over its possible negative influence on the metabolism of other essential minerals or its possible influence on the absorption of potentially toxic elements, such as manganese (Mn). In this study, Mn absorption and urinary excretion were studied in adults after intake of an Fe-fortified weaning cereal labeled with 54Mn. In a crossover design, the fortification of the weaning cereal with Fe as NaFeEDTA was compared with ferrous sulfate. Manganese absorption was measured by extrapolation from whole-body retention data 10-30 d after intake, and urinary excretion of 54Mn was measured over 7 d. No significant differences in 54Mn absorption or urinary excretion were found; 1.1 +/- 0.15 and 0.91 +/- 0.35% of the ingested dose was absorbed from the cereal fortified with NaFe(III)EDTA and FeSO4, respectively. Urinary excretion of 54Mn was very low; the total radioactivity in urine represented 1.1 +/- 0.55% of the absorbed dose with NaFe(III)EDTA and 0.72 +/- 0.53% of the absorbed dose with FeSO4. Until now, Fe-fortification programs have met with only limited success. The introduction of NaFeEDTA as a food fortificant could be a useful tool to provide bioavailable Fe to vulnerable groups in the population and thus aid in combating Fe deficiency.

The influence of meat on nonheme iron absorption in infants.

During weaning the infant has a high iron requirement, and highly available dietary iron is needed to ensure optimal iron status. Muscle tissue has been identified as an enhancer of nonheme iron absorption in adults, although the influence of meat on nonheme iron absorption in infants has not been previously reported. The effect of the addition of 25 g of meat (lean beef) on nonheme iron absorption from a home-prepared vegetable purée meal (80 g of vegetables) was investigated in infants in the present study. The meals did not differ in their contents of other known enhancers or inhibitors of nonheme iron absorption. Incorporation of stable isotopes of iron (57Fe and 58Fe) into red blood cells 14 d after intake was used to measure iron absorption, using a cross-over design in eight healthy infants 43-49 wk of age. Nonheme iron absorption was significantly increased (p = 0.002) from the vegetable purée with added meat (geometric mean 15.0%) compared with the puréed vegetables (geometric mean 9.9%). These results thus suggest that meat is also an enhancer of nonheme iron absorption in infants and that nonheme iron absorption from weaning foods can be increased by the addition of meat.

Influence of ascorbic acid on iron absorption from an iron-fortified, chocolate-flavored milk drink in Jamaican children.

The influence of ascorbic acid on iron absorption from an iron-fortified, chocolate-flavored milk drink (6.3 mg total Fe per serving) was evaluated with a stable-isotope technique in 20 6-7-y-old Jamaican children. Each child received two test meals labeled with 5.6 mg 57Fe and 3.0 mg 58Fe as ferrous sulfate on 2 consecutive days. Three different doses of ascorbic acid (0, 25, and 50 mg per 25-g serving) were evaluated in two separate studies by using a crossover design. Iron isotope ratios were measured by negative thermal ionization mass spectrometry. In the first study, iron absorption was significantly greater (P < 0.0001) after the addition of 25 mg ascorbic acid: geometric mean iron absorption was 1.6% (range: 0.9-4.2%) and 5.1% (2.2-17.3%) for the test meals containing 0 and 25 mg ascorbic acid, respectively. In the second study, a significant difference (P < 0.05) in iron absorption was observed when the ascorbic acid content was increased from 25 to 50 mg: geometric mean iron absorption was 5.4% (range: 2.7-10.8%) compared with 7.7% (range: 4.7-16.5%), respectively. The chocolate drink contained relatively high amounts of polyphenolic compounds, phytic acid, and calcium, all well-known inhibitors of iron absorption. The low iron absorption without added ascorbic acid shows that chocolate milk is a poor vehicle for iron fortification unless sufficient amounts of an iron-absorption enhancer are added. Regular consumption of iron-fortified chocolate milk drinks containing added ascorbic acid could have a positive effect on iron nutrition in population groups vulnerable to iron deficiency.

A comparison of iron absorption in adults and infants consuming identical infant formulas.

Fe absorption was estimated in adults and infants from the erythrocyte incorporation of Fe isotopes added to infant formula. Fe absorption was measured in adults using radioisotopes, and in infants with a stable-isotope technique. In adults, the geometric mean Fe absorption from a ready-to-feed soya formula with its native phytic acid content was 2.4%. This increased to 6.0% (P < 0.05) after almost complete dephytinization. In infants, mean Fe absorption values were 3.9 and 8.7% respectively from the same products (P < 0.05). In adults, mean Fe absorption from a spray-dried soya formula containing 110 mg ascorbic acid/l was 4.1%, increasing to 5.3% (P < 0.05) when ascorbic acid was doubled to 220 mg/l. In infants, mean Fe absorption values were 5.7 and 9.5% (P < 0.05) from the same products. Mean Fe absorption from a milk-based formula was 6.5% in adults compared with 6.7% in infants. All meals in the adult and infant studies were fed using an identical meal size of 217 g. Increasing the meal size threefold in adults did not change fractional Fe absorption. Mean Fe absorption values for each meal were lower in adults than in infants but the relative inhibitory effect of phytic acid and the enhancing effect of ascorbic acid were similar. We conclude that Fe absorption studies in adults can be used to assess the influence of enhancers and inhibitors of Fe absorption in infant formulas fed to infants. Further studies, however, are required to extend these findings to weaning foods and complete meals.

Intracerebral malignant lymphoma in a patient with long-standing multiple sclerosis.

We present a patient with long-standing MS who developed a malignant intracerebral lymphoma, suspected on MRI and verified by brain biopsy. This raises the interesting question about whether the coexistence of the two conditions is explained by cause or is just coincidental. Our case report also illustrates that other pathological conditions may develop in MS patients and demand attention in the individual patient. Copyright 1998 Lippincott Williams & Wilkins